Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Tuesday, September 26, 2006

Yes, all their dogs are in the hunt . . .

...but why should the drug pushers have all the horses? The American Psychological Association has just released an in-depth report on the use of psych meds in children. (56K warning: large pdf) As far as Stayin' Alive is concerned, it's another open door crashed through, but maybe some people will listen. Yes, yes, they aren't real doctors, they're doctors of philosophy, but still.

The bottom line is that (remember, you read it here first, if you happened to read it here first) kids with behavioral and emotional problems (APA goes along with the gag and calls them "mental disorders," without questioning the ontological status of the diagnoses) get drugs that have not been adequately tested for safety and long term efficacy, but they generally don't get psychosocial interventions that have been proven to work, because it's harder to get anyone to pay for them, and there aren't enough trained clinicians. A couple of money quotes:

The evidence base for treatment efficacy is somewhat uneven across disorders, with some of the most severe mental health conditions of childhood, including bipolar disorder and schizophrenia, receiving proportionally less attention from treatment researchers. Most of the evidence for efficacy is limited to acute symptomatic improvement, with only limited attention paid to functional outcomes, long-term durability, and safety of treatments. Few studies have been conducted in practice settings, and little is known about the therapeutic benefits of intervention under usual, or real-life, conditions.

. . .

It is the opinion of the working group that the decision about which treatment to use first be in general guided by the balance between anticipated benefits and possible harms of treatment choices (including absence of treatment), which should be the most favorable to the child. It is recommended that the safest treatments with demonstrated efficacy be considered first before considering other treatments with less favorable side effect profiles. For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. The preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, the working group recommends that in most cases psychosocial interventions be considered first.

The APA report goes on to consider the commonly diagnosed mental disorders of childhood in turn, beginning with our good friend Attention Deficit-Hyperactivity Disorder. (I won't get into whether not doing what children typically don't like to do -- sit quietly in rows, concentrate for long periods on boring tasks, and speak or move only with permission -- is properly called a disease. Granted, we all need to do things we don't enjoy, and this is one of them.) Anyhow, APA tells us that

Since the 1970s, a large number of studies have shown that behavioral interventions cause short-term amelioration of ADHD symptoms and impairment and that these acute effects are comparable in most domains to those obtained with low to moderate doses of stimulant medication (Pelham & Waschbusch, 1999). In contrast to the results of studies of stimulant medication that focus on improving the core symptoms of ADHD, studies of behavioral treatments have focused on improving the key domains of impairment associated with ADHD and thought to mediate long-term outcomes: parenting practices, peer relationships, and academic/school functioning (Pelham, Fabiano, & Massetti, 2005).

Hmm. Sounds to me like parents who really feel that something needs to be done might want to go to a psychologist first, instead of a drug dealer. But now you don't have to take my word for it.